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In Phase 1 of the "Advancing Dental Education in the 21st Century" project, research was conducted and published on a number of serious challenges facing dental and allied dental education, both presently and projected to 2040. Those findings informed the strategic analysis and recommendations developed in Phase 2 of the project. This report provides an overview of the Phase 2 conclusions and presents recommendations to address the challenges identified. The recommendations propose ways to educate a workforce prepared to meet the oral health needs of the population; develop a sustainable economic model that allows schools to meet their education, research, and service missions; make dental and allied dental education and practice an integral part of the larger health education and delivery systems; and keep dentistry advancing as a "learned" profession. This report begins with an Executive Summary and then presents the strategic analysis of challenges facing dental schools and allied dental programs and provides a brief explanation of the rationale for each recommendation. Two appendices are included with the report: the first summarizes discussions held at the national conference to consider the recommendations; and the second provides additional documentation of calculations used to estimate the number of new dental graduates needed in 2040.

This executive summary for Section 4 of the "Advancing Dental Education in the 21 st Century" project examines the projected oral health care delivery system in 2040 and the likely impact of system changes on dental education. Dental care is at an early stage of major changes with the decline in solo practice and increase in large group practices. These groups are not consolidated at the state level, but further consolidation is expected as they try to increase their negotiating leverage with dental insurers. At this time, there is limited integration of medical and dental care in terms of financing, regulation, education, and delivery. This pattern may change as health maintenance organizations and integrated medical systems begin to offer dental care to their members. By 2040, it is expected that many dentists will be employed in large group practices and working with allied dental staff with expanded duties and other health professionals, and more dental graduates will seek formal postdoctoral training to obtain better positions in group practices.

This article examines dental school financial trends from 2004-05 to 2011-12, based on data from the American Dental Association (ADA) annual financial survey completed by all U.S. dental schools. For public schools, revenues from tuition and fees increased 68.6%, and state support declined 17.2% over the examined period. For private schools, revenues from tuition and fees increased 38.9%, and university indirect subsidies declined 77.9% over the same period. The major factors affecting dental school expenditures were the number of students and postdoctoral students, faculty practice, and research. The findings suggest that dental schools are now more dependent financially on tuition and fees than in the past. Schools have been able to pass on increases in operating costs to students and specialty postdoctoral students. Now that growth in dentists' incomes is slowing and student debt is at an all-time high, this financing strategy may not be sustainable in the long run. This article was written as part of the project "Advancing Dental Education in the 21 st Century."

Numerous factors that underlie the need for dentists are undergoing significant changes. Three factors are especially important: 1) improvements in oral health; 2) lower expenditures per patient per year, giving dentists the incentive to treat more patients to maintain incomes that justify their investment in dental education and practice; and 3) dental schools' producing new dentists at a faster rate than the growth in the population. If these trends continue, there is likely to be a dentist surplus of between 32% and 110% by 2040. A major challenge for dental schools is to adjust the production of dentists before 2040 and not wait for market forces to reduce the surplus. Whether there will be a painful market-based solution to the problem, as there was in the 1980s, or whether a more orderly path can be found is one of the key challenges of the project "Advancing Dental Education in the 21 st Century," for which this article was written.

Five background articles in Section 2 of the "Advancing Dental Education in the 21 st Century" project examined some of the factors likely to impact the number of dentists needed in 2040: 1) the oral health of the population, 2) changes in the utilization of dental services, 3) new technologies, 4) the growth of large capitated dental group practices, and 5) the demand for dental care. With this information, a sixth background article estimated the number of dentists needed in 2040 compared to the number expected if current trends continue. This executive summary provides an overview of findings from these six articles. The data indicate major improvements in oral health, especially in upper income groups that account for 65% of practice revenues. At the same time, per capita utilization of restorative and prosthetic services has declined dramatically. No major new technologies are likely to impact the need for dentists by 2040. In a large capitated group practice, full-time general dentists treated an average of 2,100 patients per year; solo general dentists averaged 1,350. Based on the examined factors, growth in demand for traditional forms of care may slow substantially, raising the potential for a surplus of dentists in 2040. If these trends continue, the key national policy issue then would be: should schools reduce the number of graduates before market forces require them to downsize or close, or are other alternatives available?

This article examines the current safety net activities of dental schools and reviews strategies by which schools could care for more poor and low-income patients. The primary data come from the annual Survey of Dental Education, a joint American Dental Education Association (ADEA) and American Dental Association (ADA) activity. The analyses use descriptive statistics and are intended to give ballpark estimates of patients treated under varying clinical scenarios. Some 107.4 million people are underserved in comparison to utilization rates for middle-income Americans. In 2013-14, pre- and postdoctoral students treated about 1,176,000 disadvantaged patients. This is an estimate; the actual value may be 25% above or below this number. The impact of potential strategies for schools to provide more care to poor and low-income patients are discussed; these are larger class size, more community-based education, a required one-year residency program, and schools' becoming part of publicly funded safety net clinics. While dental schools cannot solve the access problem, they could have a major impact if the payment and delivery strategies discussed were implemented. This article was written as part of the project "Advancing Dental Education in the 21 st Century."

This study compared the number of patients treated per year by general dentists and dental hygienists in solo practice and by those employed by a large group practice. Information on the annual number of patient visits to solo general dental practitioners comes from the 2013 American Dental Association (ADA) Survey of Dental Practice. Patient visits were divided by 2.5 to estimate the number of patients treated annually. The data on group practices come from HealthPartners (HP) of Minnesota, a large not-for-profit medical and dental Health Maintenance Organization that accepts insurance contracts based on global budgets and is financially at risk. In 2013, solo general dentists averaged 1,350 patients, while the average HP general dentist treated 2,052 patients. HP general dentists thus treated over 700 more patients annually than did solo practitioners. This large difference has major implications for the future of the dental delivery system and dental education. This article was written as part of the project "Advancing Dental Education in the 21 st Century."

In 1926, the Carnegie Foundation for the Advancement of Teaching published a report prepared by William J. Gies, PhD, a professor of biochemistry and founder of the Columbia University College of Dental Medicine. The Gies report examined the current status of dental education in the United States and Canada and made recommendations for a new direction. This report led to major improvements in dental education and research and was a critical factor in making dentistry a learned profession. Dental and allied dental education are now challenged by a new set of issues related to financing education, improved oral health, more effective treatment technologies, and a rapidly changing delivery system. In an effort to meet these challenges, this strategic planning project first examined the current status and future trends that are likely to impact the dental profession over the next 25 years. The project was organized into six sections, and 50 authors were invited to prepare 38 articles to address these issues. The executive summaries for each section are being published in the August and September 2017 issues of the Journal of Dental Education, and the background articles are being published in online supplements to those issues. In the next phase of the project, information from the articles will be used to make strategic recommendations to assist dental schools and allied dental education programs in preparing graduates for practice in 2040 and to meet their institutions' missions for scholarship and service. This introduction presents the project rationale, provides a list of the published articles, and acknowledges the organizations that supported this effort., (© American Dental Education Association.)

This article estimates the impact of dental therapists treating children on Federally Qualified Health Center (FQHC) dental clinic finances and productivity. The analysis is based on twelve months of patient visit and financial data from large FQHC dental clinics (multiple delivery sites) in Connecticut and Wisconsin. Assuming dental therapists provide restorative, extraction, and pulpal services and dental hygienists continue to deliver all hygiene services, the maximum reduction in costs is about 6 percent. The limited impact of dental therapists on FQHC dental clinic finances is because 1) dental therapists only account for 17 percent of children services and 2) dentists are responsible for only 25 percent of clinic expenses and cost reductions are related to the difference between dental therapist and dentist wage rates.

This article examines the history, current status, and future direction of community-based dental education (CBDE). The key issues addressed include the reasons that dentistry developed a different clinical education model than the other health professions; how government programs, private medical foundations, and early adopter schools influenced the development of CBDE; the societal and financial factors that are leading more schools to increase the time that senior dental students spend in community programs; the impact of CBDE on school finances and faculty and student perceptions; and the reasons that CBDE is likely to become a core part of the clinical education of all dental graduates.

In community-based dental education programs, student-provided services can be an important source of community clinic and practice revenues. The University of Michigan School of Dentistry has developed a revenue-sharing arrangement with multiple community clinics and practices. During their ten-week externship, senior students produce at least $800 a day in patient care revenues, and the school receives an average of $165 per student per day from community sites. These funds are used to cover program costs and enrich the curriculum. Revenue-sharing with community clinics and practices helps to ensure program longevity and is an increasingly significant source of school revenues.

Dental schools are hard pressed to find the resources to adequately fund their mission of education, research, and service. Over the years, schools have tried to make up for the loss in public funds by increasing student tuition, increasing enrollment, and reducing the growth in faculty and staff salaries and program costs. Unfortunately, these strategies have not solved the financial problems. Declining resources are threatening the future of dental education. Data presented in this report attempt to answer the following question: will community-based dental education restore the fiscal health of dental schools and provide students an equal or better education? By reducing the number of chairs per student and developing revenue-sharing relationships with community clinics, community-based dental education offers a realistic option for putting dental schools on a solid financial footing.

The financial impact of community-based dental education on dental school and community clinic budgets is a major issue. The evidence suggests that community experiences for dental students of fifty or more days, if effectively managed, can increase school net revenues due to the following factors: 1) the community rotations increase student productivity, approximating the loss of dental school clinical income; 2) the reallocation of unused clinical resources at the dental school reduces student clinic deficits; 3) schools and federally qualified health centers (FQHCs) that share surplus student patient revenues generate additional net income; and 4) enrollment of more students without additional new facilities and faculty increases total school tuition revenues. For FQHC dental clinics, student rotations increase the number of patients treated and may generate surplus revenues. Community-based dental education also provides schools and clinics important non-financial advantages.

Disparities in access to dental care are a major problem in the United States. Effectively run community-based dental education programs can make a significant contribution to reducing access disparities and at the same time enrich the educational experiences of dental students and residents. For complex historical reasons, dental schools did not base their clinical training programs in community hospitals and clinics like the other health professions. Now, because of trends in school finances, changes in societal values, and limitations in current educational experiences, schools are increasing the time students spend in community clinics. This is likely to continue. The chapters in the first section of the report on the Pipeline, Profession, and Practice: Community-Based Dental Education program--for which this chapter serves as an introduction-provide detailed information on the operation of community-based education programs.

This article presents a literature review of cultural competency education in the health professions (dentistry, dental hygiene, medicine, and nursing) with specific reference to methods of evaluating student and resident knowledge of cultural competency concepts and practices and clinical performance. Some important barriers to developing evaluation instruments are the following: 1) little consensus on core competency knowledge; 2) erroneous notions of race; and 3) stereotyping the behavior of racial groups. The relative advantages of the different examination methods now used to evaluate students and residents (qualitative, quantitative, practical, and self-evaluation) are reviewed, and recommendations are made regarding three instruments that schools can use to assess student knowledge and clinical performance.

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Funded by The Robert Wood Johnson Foundation and the California Endowment and with student financial aid from the W.K. Kellogg Foundation, the primary goal of the Pipeline, Profession, and Practice: Community-Based Dental Education program is to reduce disparities in access to dental care. In a national competition, fifteen dental schools were selected to participate. By the final year (2007) of the five-year project, the schools are expected to achieve three objectives: 1) increase the time (sixty days/year) that senior students and residents spend in patient-centered community clinics and practices treating underserved populations; 2) provide didactic and clinical courses for students and residents that prepare them for their community experiences; and 3) recruit more underrepresented minority and low-income students. The national program office that directs the project is located at Columbia University, and a national advisory committee oversees the program for the sponsoring organizations. The challenge is to demonstrate that the Pipeline objectives are achievable and that the program is sustainable without external support.

In 2000, the thirty-six states with public dental schools provided an average subsidy of 49,347 dollars per dental student. In contrast, nineteen states provided little or no subsidy. Since states invest in dental education, in part, to ensure an adequate supply of dentists, we examined the factors that explain dentist variation among states. We found that population size, per capita income, and the number of students from the state enrolled in dental school had a significant and positive impact. The level of state support for dental education and the presence of a dental school had a negative or nonsignificant effect, respectively. Apparently, dentists locate based primarily on the demand for their services and, to a lesser extent, on where they were raised. The states' investment in dental education had little impact on number of dentists because some states had many dentists but invested little in dental education. We identified two states that collectively account for 15 percent of enrolled students even though they provide minimal subsidy for dental education. We discuss the implications of these findings for states that do not have dental schools and need more dentists. This research was supported in part by grants from the Connecticut Health Foundation (Dental Workforce in Connecticut: Issues and Options), the Robert Wood Johnson Foundation, and the California Endowment (Pipeline, Profession, and Practice: Community-Based Dental Education).

It has long been recognized that tooth crown diameters in hominoids are all positively intercorrelated one with another. This study reports on sex-specific correlation matrices derived from 2,650 individuals from the Solomon Islands, Melanesia. Mesiodistal and buccolingual diameters of all permanent teeth from one side are used, excluding third molars. Analysis discloses significant sex dimorphism in the strengths of the intercorrelations, with females being better integrated. Principal components analysis (PCA) provides an objective means of data reduction (shown here to be preferable to simple size summation methods) and decorrelation of the resulting linear combinations. Four components are extracted (with results being virtually identical in the two sexes) and arguments are put forth that varimax rotation to "a simpler solution" may be counterproductive. Before rotation, the four components are 1) overall size, 2) buccolingual widths contrasted with mesiodistal lengths, 3) anterior (I,C) contrasted with posterior (P,M) teeth, and 4) premolars contrasted with molars. Most of the explained (shared) variance (63%) extracted by PCA is in overall size of the dentition. There is a strong urge to view the results of these principal components analyses as reflective of biologically and genetically meaningful entities.

Factor-analytic studies of human tooth size routinely exhibit separate factors for the mesiodistal and buccolingual dimensions of anterior teeth but a single factor each for premolar and molar size. This observed independence within the anterior field is shown to be attributable to a much larger effect of environmental factors on the buccolingual vs. the mesiodistal diameters, a significant cause of which may be calculus accumulation hitherto unrecognized in the relevant literature. The heritability of dental dimensions is also discussed.

Incidence and size variability of the metaconule, an accessory maxillary molar cusp, is analyzed in a series of 1,217 living Melanesians. The range of morphologic variation is quantified on a six-grade ordinal scale developed to standardize observations. Total incidence of the metaconule decreases along a mesial-to-distal gradient, while mean size and size variability increase from M1 to M3. So, while the trait is less common on distal molars, it is on average larger. Estimation of the additive genetic component is 65% for the first molar but only 15% for the second. Trait incidence and heritability estimates are generally higher for females indicating the need for separate analysis by sex.

Population studies of malocclusion lack comparability because of the subjective criteria employed in the definition of malocclusion. Alternatively, individual characteristics of occlusion can be quantified and compared within and between populations. Measurements were taken from the dental cases of 319 male an 359 female Melanesians from Bougainville, Papua New Guinea. The cross-sectional age changes from 12 to 68 years of age included an increase in intermolar arch width, a decrease in arch length and intercanine arch width, and increased crowding and malalignment. Neither age nor sex accounted for a large proportion of the differences among individuals. When compared to industrialized groups, the Bougainville population had a slight reduction in variance for most characteristics. Only the sagittal molar relationship was markedly less variable on Bougainville. The results emphasize that a quantitative evaluation of individual occlusal variables may reveal differences within and between populations not detected when simple malocclusion frequencies are reported.